Using the Nutrition Care Process for Integrative and Functional Nutrition - PowerPoint Presentation

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Using the Nutrition Care Process for Integrative and Functional Nutrition

Kelly Morrow, MS, RDNCynthia Bartok, PhD, RDNMay 10, 2018

© 2018 Morrow and BartokSlide2

Today’s Presenters

Cynthia Bartok, MS, RDNAssociate Professor2

Department of Nutrition and Exercise Science

Bastyr

University, Kenmore, WA

Kelly Morrow, MS, RDN, CD, FAND

DIFM-Immediate Past Chair

Associate ProfessorSlide3

Objectives

By the end of today’ presentation the attendee will be able to:Summarize the consistencies between the Nutrition Care Process (NCP) model and Integrative and Functional Nutrition (IFN) careWhen needed, creatively use the NCP model and terminology to provide IFN care Develop PES statements and interventions using NCP

terms that address IFN perspectives on health, disease, and

delivery of care

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Outline

The NCP model as a foundation for IFN careCommonalities between the IFN radial and NCP Assessment TerminologyCase Study:Creative application of the NCP Diagnosis Terminology when providing IFN careNCP Intervention Terminology that aligns with IFN principles of care

NCP

Monitoring and Evaluation strategies that allow for deeper exploration of underlying causes of disease

Future directions for NCP terminology

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The NCP model as a foundation for IFN care

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Principles of the Nutrition Care Process (NCP)

The Nutrition Care Process (NCP) is a patient-centered, standardized process for providing care that increases the likelihood of positive outcomes1Standardized approach results in consistent, high quality nutrition careProcess identifies and addresses the root cause of nutritional problems

Focus is on delivery

of evidence-based nutrition

interventions

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1

Academy of Nutrition and Dietetics. Nutrition care process and nutrition monitoring and evaluation. In: Nutrition Terminology Reference Manual (eNCPT): Dietetics Language for Nutrition Care [Internet]. Chicago: Academy of Nutrition and Dietetics; 2017 [cited 2018 April 29]. Available from:

https://www.ncpro.org/pubs/idnt-en.2 Slide7

Integrative and Functional Nutrition (IFN) Care1

Integrative approach:Person-centered, prevention- and wellness-orientedIdentifies and addresses the root cause of diseaseIntegrates conventional and functional medicine interventions

Functional

Nutrition

approach:

Each client is an individual with a:

Unique genetic makeup

Unique biochemistry and metabolic patternUnique environment and lifestyleUnique “story” of antecedents, triggering events, and mediators/perpetuators of health problemsInteractions among the individual’s unique biology, environmental exposures (positive and negative), and lifestyle are important to prevent, explain, and treat disease

71Ford D, Raj S. Batheja RK, et al. American Dietetic Association: Standards of Practice and Standards of Professional Performance for Registered Dietitians (Competent, Proficient, and Expert) in Integrative and Functional Medicine JADA 111: 902–913, 2011.Slide8

nCP Step 1: Nutrition Assessment

Nutrition Assessment is a systematic process of obtaining, verifying, and interpreting data needed to identify nutrition-related problems, their causes, and significance1.IFN Approach2:

Integrative and Functional Medicine Matrix

Functional Medical Nutrition Therapy Radial

Nutrition:

foods,

bioactives

, dietary supplements, toxin exposuresBiochemistry: metabolome, geneticsAnthropometry: body compositionNutrition focused physical exam and Medical Symptom Questionnaire

81Academy of Nutrition and Dietetics. Nutrition care process and nutrition monitoring and evaluation. In: Nutrition Terminology Reference Manual (eNCPT): Dietetics Language for Nutrition Care [Internet]. Chicago: Academy of Nutrition and Dietetics; 2017 [cited 2018 April 29]. Available from: https://www.ncpro.org/pubs/idnt-en/page-001.2Ford D, Raj S. Batheja RK, et al. American Dietetic Association: Standards of Practice and Standards of Professional Performance for Registered Dietitians (Competent, Proficient, and Expert) in Integrative and Functional Medicine JADA 111: 902–913, 2011.Slide9

nCP Step 2: Nutrition Diagnosis

Nutrition Diagnosis is a specific nutrition problem that can be resolved or improved through treatment/nutrition intervention by a nutrition and dietetics practitioner1.IFN Approach2:Evidence-based and practice-based aspects to prioritization of diagnoses

Incorporates IFMNT data into PES statement

Identifies root of nutritional problem

9

1

Academy of Nutrition and Dietetics. Nutrition care process and nutrition monitoring and evaluation. In: Nutrition Terminology Reference Manual (

eNCPT

): Dietetics Language for Nutrition Care [Internet]. Chicago: Academy of Nutrition and Dietetics; 2017 [cited 2018 April 29]. Available from: https://www.ncpro.org/pubs/idnt-en/category-2.2Ford D, Raj S. Batheja RK, et al. American Dietetic Association: Standards of Practice and Standards of Professional Performance for Registered Dietitians (Competent,Proficient, and Expert) in Integrative and Functional Medicine JADA 111: 902–913, 2011.

Example: Excessive vitamin intake (Vitamin A, NI-5.9.2.1)

related to

food- and nutrition-related knowledge deficit concerning vitamin supplements

for preconception

as evidenced by

elevated serum retinol concentration and reported intake of 5,000

ug

retinol/day (166% of UL) via supplements.Slide10

nCP Step 3: Nutrition iNTERVENTION

Nutrition Intervention is a purposefully planned actions intended to positively change a nutrition-related behavior, environmental condition, or aspect of health status for the patient/client, community, or population1.IFN Approach2:Evidence-based and practice-based intervention

strategies

Addresses root of nutritional problem, core imbalances

Goal is client wellness

Incorporation/referral to complementary care

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1

Academy of Nutrition and Dietetics. Nutrition care process and nutrition monitoring and evaluation. In: Nutrition Terminology Reference Manual (eNCPT): Dietetics Language for Nutrition Care [Internet]. Chicago: Academy of Nutrition and Dietetics; 2017 [cited 2018 April 29]. Available from: https://www.ncpro.org/pubs/idnt-en/category-2.2Ford D, Raj S. Batheja RK, et al. American Dietetic Association: Standards of Practice and Standards of Professional Performance for Registered Dietitians (Competent,Proficient, and Expert) in Integrative and Functional Medicine JADA 111: 902–913, 2011.Slide11

nCP Step 4: Nutrition Monitoring & Evaluation

Nutrition Monitoring & Evaluation includes:data collection (reassessment)data review (monitoring)data analysis (evaluation)to determine whether the client is meeting the nutrition intervention goals or desired outcomes

1

.

IFN Approach

2

:

Broad reassessment and review of IFN dataConsideration of core imbalances at the root of persistent problemsConsideration of the individual response to the intervention provided

111Academy of Nutrition and Dietetics. Nutrition care process and nutrition monitoring and evaluation. In: Nutrition Terminology Reference Manual (eNCPT): Dietetics Language for Nutrition Care [Internet]. Chicago: Academy of Nutrition and Dietetics; 2017 [cited 2018 April 29]. Available from: https://www.ncpro.org/pubs/idnt-en/category-2.2Ford D, Raj S. Batheja RK, et al. American Dietetic Association: Standards of Practice and Standards of Professional Performance for Registered Dietitians (Competent,Proficient, and Expert) in Integrative and Functional Medicine JADA 111: 902–913, 2011.Slide12

Commonalities between the IFN radial and NCP Assessment Terminology

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IFMNT Radial

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Web-like connections between core areas of imbalance

Incorporates aspects of the patients:

lifestyle

(client history)

signs and symptoms

(nutrition physical)

biomarkers (lab assessment),metabolic pathways and networks (nutrition focused physical, nutrition and lab assessment)Slide14

IFN Nutrition Assessment Terminology

Nutrition assessment categories include IFN core areas of imbalance Cellular IntegrityNutrition focused physical exam and biochemical assessment, nutrition intake including quality and quantity of fats, multiple micronutrients such as vitamin A, folate,choline…DigestionNutrition focused physical exam, bioactive substance intake (prebiotics / probiotics), fiber, physical activity, hydration, client history (stress)Energy MetabolismLab assessment, nutrition focused physical, mitochondrial support nutrients, anthropometric assessmentSlide15

IFN Nutrition Assessment Terminology

Nutrition assessment categories include IFN core areas of imbalance Inflammation / Oxidative StressLab assessment, nutrition physicalNeuro/Endocrine ImbalanceLab assessment, environmental exposuresNutritional StatusComplementary and alternative medicine, macronutrient quantity and quality, bioactive substance intake, knowledge and beliefs, physical activitySlide16

Case Study Example

Migraines16Slide17

Meet Joseph

39 yo White male with 20 year history of chronic migraines (1-2x/week – daily) and ADHDClient History:Migraines may be mild enough to “live with” but occasionally result in missed work Self-management: Coke (caffeine, sugar), pizza, burgers (salt); avoid alcohol (trigger)Medical management: Imitrex (Migraine), Xanax (Sleep), Propenolol (HTN medication used for migraines

), Adderall (ADHD); chiropractic

care/manipulations

Social:

High responsibility managerial role at

Amazon; married

with 3 children under age of 4; relocated to Seattle 1 yr ago from East CoastEnvironment: new house (carpet, paint); allergies to dust, trees, smoke

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Meet Joseph

Food and Nutrition-Related History:Assessment: On average consumes 3 meals and 1 snack per/d. Skips lunch occasionally due to time constraints or appetite suppression(Adderall). Current diet includes many high glycemic and convenience foods. Compared to Basytr Healthy

plate:

1 serving of fruit and 1 serving of vegetables/d (L), 1-2 servings of whole grains and starches (L), 2-3 serving

protein

(adequate), 0 servings of healthy fat and

digestives/fermented foods

(L). Diet contains multiple high histamine and tyramine foods.Typical Day:B (630a-7a): cereal - raisin bran or puffed rice with 2

% milk and occasional fruit such as strawberries, raspberries, or blueberries, orange juice and coffee w/ creamL (130p): take out from food trucks - chicken and cheddar quesadilla, pizza 1-2x/wk, or deli meat sandwichD (6p-7p): typically homemade - protein (chicken or beef), starch or grain (pasta, rice or potatoes), and salad (often spinach salad with parmesan cheese, tomatoes, vinaigrette dressing. Likes olives and pickles too) Snack (8p): ice cream or something else sweet like OreosBeverage and ETOH intake: 48 oz water/d; 1-2 Cokes/d; 20 oz coffee/d (more than 20 oz triggers migraine); ETOH 1-2x/mos in social settings18Slide19

Meet Joseph

Anthropometric Measures:Height (in/cm): 71 in/180.3 cm Weight (lb/kg): 205 lb/ 93.2 kgBMI: 28.6 (“normal”)Weight

hx

: 3

% increase in previous 12 months

Biochemical Data, Medical Tests and Procedures

:

Blood glucose: 93 mg/dL (high end of normal)Hemoglobin A1C: 5.4% (high end of normal)

Cholesterol: 201 mg/dL (elevated)Triglycerides: 145 mg/dL (high end of normal)19Slide20

Meet Joseph

Nutrition Focused Physical Exam FindingsGI Function: in past dairy caused diarrhea; stools are loose after breakfast daily Sleep hx: 6 hr/night often interrupted; takes Xanax if wakes in middle of nightEnergy: 4/10Stress: moderate r/t migraines and busy scheduleBlood pressure: 118/76 mm Hg (normal)Physical exam: fidgeting/leg bouncing; appears well-nourished with good skin color; slight central adiposity

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IFN-Based Nutrition Assessment

Core Areas of Imbalance:Cellular Integrity: nerve functionEnvironmental Exposures: home (?), allergensInflammation/Oxidative Stress: potential for neurogenic inflammationNutritional Status: predicted low EFA, Mg, Vitamin B6, folate, water; high glycemic diet; highly processed food sources; low whole-foods; low protective bioactive compounds; high intake of tyramine and histamine foods; food sensitivities/allergens/intolerances (?)Lifestyle:Poor sleep; high stress; sedentary; low PA;

high-demand family and work life

Learned patterns of migraine management using low quality foods

Signs & Symptoms/Nutrition Physical:

Nervous system instability

, chronic migraines

Skeletal - symptoms improved with chiropractic careCentral adiposity, weight gainBiomarkers:Concerning FBG, A1

C, cholesterol; trend towards metabolic syndrome (?)Metabolic Pathways/Networks:Predicted low intake of micronutrients and EFA to support nervous system functionDNI, including nutrient depletions21Slide22

IFN-Based Strategy

IFN Assessment reveals a interconnected map of potential contributors to migrainesEvaluate what is within our scope of practice vs. referrals/inter-professional integrationRDN Scope: Evidence-based and practice-based consideration of dietary factors that increase migrainesPatient-centered approachGeneralized to personalized education on potential contributors to migrainesPatient input into sequence of interventions based on what is realistic, preferable, high impact

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IFN-Based Nutrition Diagnosis/Intervention

Priority #1: Low nutrient/high glycemic diet that may contribute to poor nervous system function and poor blood glucose controlDiagnosis: Undesirable food choices (NB-1.7) related to knowledge deficit regarding dietary and lifestyle factors that influence migraines as evidenced by low intake of whole foods including anti-inflammatory vegetables, whole grains, legumes, nuts and seeds vs Bastyr Healthy Plate standards.Intervention: Foods-based nutrition education to gradually improve diet

quality; focus on easy to prepare meal and snack ideas that are

nutrient dense

and low in glycemic load; emphasis on magnesium, B-vitamin, and EFA-rich food choices;

immediate support through a

MVM;

monitor whether migraine severity and frequency decrease.23Slide24

IFN-Based Nutrition Diagnosis/Intervention

Priority #2: High intake of tyramine and histamine foods which may exacerbate migrainesDiagnosis: Excessive bioactive substance intake (NI-4.2) related to preference for convenience foods and as evidenced by typical intake of high tyramine and histamine foods like cheese, vinegar based dressing, deli meats, and cola.Intervention: Nutrition education on the potential relationship between tyramine, histamine, and migraines; nutrition education on food and beverage choices that are lower in tyramine and histamine; monitor whether migraine severity and frequency decrease.

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IFN-Based Monitoring and Evaluation

Based on a broader set of assessment data and interventions, the IFN care provider1 can:Consider the individual response to the intervention providedEvaluate progress towards a reduction in disease or towards enhanced wellness

Evaluate progress (or lack of progress) through assessment of key IFN data and Core

Imbalances (i.e. go back to original assessment “roadmap”; assess new data):

Lifestyle – e.g. stress, limited time for self-care, activity level

Signs and Symptoms

- Medical symptom questionnaire (MSQ)

resultsBiomarkers and Metabolic Pathways/Networks - e.g. functional lab assessment

Allergens/IntolerancesEnvironmental exposures and elimination – e.g. functional lab assessmentGenetics – e.g. MTHFRDetermine whether referrals to other providers is indicated and/or has been helpful to client251Ford D, Raj S. Batheja RK, et al. American Dietetic Association: Standards of Practice and Standards of Professional Performance for Registered Dietitians (Competent, Proficient, and Expert) in Integrative and Functional Medicine JADA 111: 902–913, 2011.Slide26

Conclusions an future directions for NCP terminology

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Key Points

Many NCP Assessment, Diagnosis, and Intervention terms fit well within a context of IFN careSometimes, IFN care can require creative use of NCP DiagnosesCases with stress, fatigue, environmental exposures: No diagnoses specifically capture these problems; often include these as etiologies of identified nutrition problems“Catch-all” Diagnoses include Undesirable Food Choices (NB-1.7) and Food- and Nutrition-related Knowledge Deficit (NB-1.1)No foods-based diagnoses in the Intake Domain (stated preference of NCP)Requirement to name one nutrient problem

per

PES, while IFN care involves interconnected, multi-nutrient problems

Opportunities to request changes to the NCP:

https

://www.ncpro.org//404.cfm?404;http://ncpt.webauthor.com:80/terminology-submission-processSlide28

Questions?

Cynthia Bartok, MS, RDNAssociate Professor© 2018 Morrow and Bartok28

Department of Nutrition and Exercise Science

Bastyr

University, Kenmore, WA

Kelly Morrow, MS, RDN, CD, FAND

DIFM-Immediate Past Chair

Associate ProfessorSlide29

References

Kohn, JB. Is There a Diet for Histamine Intolerance? Journal of the Academy of Nutrition and Dietetics;114(11):1860 Borkum JM. Migraine Triggers and Oxidative Stress: A Narrative Review and Synthesis. Headache. 2016 Jan;56(1):12-35Sun-Edelstein

C,

Mauskop

A. Role

of magnesium in the pathogenesis and treatment of

migraine. Expert

Rev Neurother. 2009 Mar;9(3):369-79. doi: 10.1586/14737175.9.3.369.Ramsden et al. Targeted alteration of dietary n-3 and n-6 fatty acids for the treatment of chronic headaches: A randomized

trial. Pain.2013;154(11):2-22Izquierdo-Casas J et al. Low serum diamine oxidase (DAO) activity levels in patients with migraine. J Physiol Biochem.2018 Feb;74(1):93-99Tox Town: Environmental Health Concerns and Toxic Chemicals Where you Live, Work and Play. https://toxtown.nlm.nih.gov/ 29Slide30

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https://my.clevelandclinic.org/ccf/.../Medical%20Symptoms%20Questionnaire.pdf Slide31

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